2013-2014 Minimal Income Statement Form (LIVE Form) Dependent

You reported an unusually low amount of household income on your 2013-2014 Free Application for Federal Student Aid (FAFSA). In order to document how the household was maintained on this amount of income, please complete this form.

Dependent Students need to complete information for both students and parents. If any question is left unanswered, this form will be returned to you, which will delay your application process.

Fields marked with an asterisk (*) are required fields

Dependent Student's Information

First Name:

*

Last Name:

*

NLU ID Number:

*

(Example: N00123456)

Date of Birth:

*

/
/

Address:

*

City:

*

State:

*

Zip:

*

Email:

*

Phone Number:

*

Alternate Phone Number:

Parent Date of birth:

*

/
/

Income and Support

Please be specific and report information for the calendar year 2012, not the current year. Parent information is required when the student is considered Dependent.

Parent Source of Income and Support:

Parent(s)/Step-parent(s):Gross Amount Received for the Year 2012(Do not use grandparent(s) information)

Mother/Step-Mother's Income from work.(Provide all W2s)

$

Father/Step-Father's Income from work.(Provide all W2s)

$

Unemployment

$

Workman's Comp

$

Food Stamps

$

Child Support

$

Financial Aid used for Living Expenses

Yes
No
Amount: $

Parent/Other Relatives/Friend

$

SSI

$

Disability

$

Welfare

$

AFDC

$

TANF

$

WIC

$

Veteran's Non-education Benefits

$

Other Source

$
Please describe: *

Student Source of Income and Support:

StudentAmount Received for the Year2012

Student's Income from work.(Provide all W2s)

$

Spouse's Income from work.(Provide all W2s)

$

Unemployment

$

Workman's Comp

$

Food Stamps

$

Child Support

$

Financial Aid used for Living Expenses

Yes
No
Amount: $

Parent/Other Relatives/Friend

$

SSI

$

Disability

$

Welfare

$

AFDC

$

TANF

$

WIC

$

Veteran's Non-education Benefits

$

Other Source

$
Please describe: *

Provider

To be completed by Parent(s)/Step-parent(s): (Dependent Students Only)

Who provides the following to the Parent?

Amount per month

From what source is this being paid? (i.e. I lived with aunt; money earned from my job; I lived with friend)

Car expenses, Gas, Insurance, Bus fare

$ *

*

Rent/Mortgage

$ *

*

Utilities

$ *

*

Food

$ *

*

Personal Care (clothing, hygiene, etc.)

$ *

*

Use the space below to provide additional comments needed to explain how the household was maintained on the reported income and to report changes in income and/or living accommodations.

Certification and Signature

By printing my name below, I certify that all of the information reported on this worksheet is complete and correct.

WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.

CHICAGO DOWNTOWN CAMPUS

NLU’s Chicago campus on South Michigan Avenue occupies five floors of the historic Peoples Gas Building. This landmark building, across the street from the Art Institute of Chicago and Grant Park, is easily accessible by train, bus and car and is surrounded by restaurants, parking lots/garages and shops.

ELGIN

Conveniently located in a fast-growing business district off I-90 and Route 31, NLU Elgin features 10 classrooms with high-tech media equipment; a computer lab with high-speed Internet access; two conference rooms; and comfortable student lounges. Parking is free at this recently remodeled and upgraded teaching site, which now includes wireless Internet access.

NORTH SHORE

Opened in the summer of 2006, NLU North Shore at Skokie is a state-of-the-art modern campus located just off the Edens Expressway near the Old Orchard Shopping Center. The campus includes 44 wireless classrooms equipped with high-tech media equipment; four computer labs with high-speed Internet access, including a walk-in lab in the library; six conference rooms; a public café for beverages and snacks; a student welcome center; a library for research and study; and multiple, comfortable student lounge areas.

LISLE

Located just minutes from the East-West Tollway (I-88), NLU Lisle features 42 wireless classrooms equipped with high-tech media equipment; four computer labs with high-speed Internet access, including a separate walk-in lab in the library; a café for beverages and snacks; a student welcome center; a library for research and study; conference rooms; and six comfortable student lounge areas with wireless access.

WHEELING

Located in one of Chicago's major northwest suburbs, the newly renovated NLU Wheeling includes 20 classrooms with high-tech media equipment, four conference rooms, four computer labs with high-speed Internet access, large student lounge areas with wireless capabilities and interactive video capabilities, and an extensive research library. The site also houses the university library research collection.

FLORIDA (TAMPA)

Established in 1988 and located in one of the city's major business districts, NLU's Florida Regional Center serves students in 13 counties in central Florida. In addition to six classrooms, this location features a conference room, a computer lab with high-speed Internet access, an extensive research library and comfortable student lounges.

WISCONSIN

NLU's Milwaukee campus has a proud history of serving graduate students in education in southeastern Wisconsin. Nearly one in five certified Wisconsin teachers looks to NLU for graduate education programs – more than any other university in the state. In addition to classrooms with high-tech media equipment, the campus offers a state-of-the-art computer lab with wireless Internet access and an extensive IDS research library.